Laserfiche WebLink
�Appiications Will Be Processed When Submitted Properly omp e e � <br /> Pro APPLICATION <br /> FQR OFFICE USE: PUMP&WEA <br /> S (Far Non-Transferable,.Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT A f�Ld Co�5-�I <br /> Ili' :r <br /> WATER QUALITY ork <br /> (COMPLETE 1N TRIPLICATE) thew <br /> Application is hereby made to the San Joaquin Local Health D�s1B62 a dor a pthe rules and regulations oftthle San//Jo quint Local cHealtthTDistrhis riiccplication Is <br /> made in compliance with San Joaquin County OrdinanceCity/Town <br /> g E /Q <br /> Exact Site Address �T <br /> Phone S3 <br /> fr �� <br /> Owner's Name �I d( City__-,4 ��• ell <br /> Address f� f�;A► License# Business Phone <br /> 00 <br /> 8' 67 <br /> ts Name <br /> ' <br /> Contracor �c'vr rho <br /> 110V d LA-Ernergency Phone <br /> Contractor's Address No " <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes ❑ DESTRUCTION❑ <br /> TYPE OF WORK (CHECK): NEW WELLS DEEPEN ❑ RECONDITION PUMP REPAIR❑ <br /> WELL CHLORINATION Cl WELL ABANDONMENT ❑ OTHER ❑ PUM/�P, ITALLATIQN� <br /> REPLACEMENT❑ n f l(p d f-T Pit Privy �G -- <br /> i ) t0�f--/" Sewer Lines apt/ ~ <br /> E DISTANCE TO NEAREST: Septic Tank LP' Cesspool/Seepage Pit /Ve /V C' Other <br /> Sewage Disposal Field / col <br /> Property Line <br /> Private Domestic Well A•+PQ- Public Domestic Well <br /> TYPE OF WELL <br /> INTENDED USE >r£ABLE TOOL Dia. of Well Excavation <br /> 11 INDUSTRIAL <br /> ❑ DRILLED Dia. of Well Casing <br /> DOMESTICIPRIVATE �a <br /> ❑ DRIVEN Gauge of Casing <br /> ❑ DOMESTIC/PUBLIC ❑ GRAVEL PACK Depth of Grout Seal <br /> El IRRIGATION Type of Grout <br /> m�� <br /> 13 CATHODIC PROTECTION ❑ ROTARY <br /> EI OTHER Other Information <br /> 11 DISPOSAL Surface Seal Installed By: <br /> 11 GEOPHYSICAL f N y /c <br /> Z c 1-131, <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: <br /> ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> be I I hereby certify that I have prepared this application <br /> the San t the nock willHealtdh one iDistrrictccordance with San Joaquin County <br /> 1 ordinances, state laws, and rules and regulations <br /> Home owner or licensed agent's signature certifies the following-."I certify1that in the performancom meati k for laws <br /> owhich this permit <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> following:"I certify that in the performance of the work for which this <br /> Contractor's hiring or sub-contracting signature certifies the <br /> '.permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I ll call for a Grou_VIIction prior to grouting and a final inspection. Date: <br /> g Title: 030 <br /> Signed X (Draw Plot Plan on Reverse Side) _. <br /> t FOR DEPARTMENT USE ONLY <br /> Y Date 4'1 <br /> 7 <br /> PHASE I <br /> Application Accepted By <br /> Additional Comments: phase I i Final In ectionr / <br /> " ase 11 Grout Inspection IC�l1 Date <br /> . � Date_ ��'��� Inspection By <br /> I. -�jnspection By <br /> 31 <br /> REMIT <br /> Fee IS Due: Cl ANNUALLY ❑ PER UNIT El PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July� &Rece'CHECKEDved By y <br /> BILLING REMITTANCE $ AMOUNT DUE <br /> BASE EXPLANATION DATE REMITTED AMOUNT <br /> GATE � ¢ <br /> I FEE O <br /> F LESS 'F <br /> PRORATION <br /> - <br /> PLUS f <br /> I PENALTY <br /> 4 OTHER - -. - <br /> 4 OTHER <br /> 1. issuance DaSe Mailed Delivered <br /> Receipt No. a if o. <br /> Received by - ate tgpj E.HAZELTON AVE..P.O:90x 2005 STOCKTON,CA 95201 <br /> woe=ICeNT—RETURN ALL'COPIES TO: ENVIRONMENTAL HEALTH PERM <br /> ITISERVICES <br />